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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CT-Rs GONVIN tC'A)M s-1-0kC `A Q 0 Iib -S RaN 1 -70Co <br /> OWNER I OPERATOR <br /> ' I n 0 I C CHECK If BILLING ADDRESS <br /> FACILITY NAM ,J ,20 (q 4A-Q N l4 <br /> SITE ADDRESS rri �sc.�9ivY� ROAD <br /> SbGKTon� �s�,�j <br /> Street Number Direction ��W tee Na <br /> I Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> IS GI`rc'`:.- Ic C-I Street Number tree Name <br /> CITY STATE ZIP �S---7 <br /> PHONE#1 EXT. APN# D LAND USE APPLICATION# <br /> ( °I1G) v io3 l a�117 O <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( Icy) 3S S'C6 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR —T`Tr,,,,q <br /> '�Y��� 1 CHECK 1f BILLING ADDRESS Eir <br /> BUSINESS NAME 1, � f N-A PHONE# ExT' <br /> HOME or MAILING ADDRESS 1"L FAX# <br /> !% -- ( ) <br /> CITY STATE zip 'rl <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: r DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPEWTORAIANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PART) proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmen �s1►�ass�essmen.t <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at ht� it s <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: 14 M I a+1 0 Q <br /> COMMENTS: SA/V JOgQUI ?©2® <br /> MFq'rfy,PMRTTA�� <br /> MFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: / -20� <br /> ASSIGNED TO: �O P.Z EMPLOYEE#: DATE: 44 a 0 <br /> Date Service Completed (if already completed): SERVICE CODE: P f E: I q Q <br /> Fee Amount: Amount Paid -1i i — Payment Date <br /> Payment Type Invoice# I Check# DULe Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />